MEDICARE: KYLE PALMER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3659ATI	OR

General Provider Information

NPI Number	:	1588014344
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KYLE PALMER

Provider Business Mailing Address
First Line	:	15480 BOONES FERRY RD
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-3429
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	15480 BOONES FERRY RD
Second Line	:
City	:	LAKE OSWEGO
State	:	OR
Zip	:	97035-3429
Country	:	US
Telephone Number	:	503-635-1458
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/13/2016
Last Update Date	:	08/25/2016

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Directions to “ KYLE PALMER ” Practice Location

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